Laparoscopic TME dissection with monopolar cautery

Authors

Abstract

We present the case of a TME dissection performed with monopolar cautery. A good knowledge of the anatomy and adequate surgical skills permit to effectively complete the mesorectal excision.
This video is recommended for advanced digestive surgeons.

Classification

basic techniques

Keywords

Laparoscopic TME dissection, monopolar cautery, total mesorectal excision

Media type

Duration

26'46''

Publication

2008-12

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Subtitles

E-publication

WeBSurg.com, Dec 2008;8(12).
URL: http://www.websurg.com/doi-vd01en2453.htm

Laparoscopic TME dissection with monopolar cautery

1. Exposure and landmark identification 00'25''

First step is the exposure, for that we put the patient head down. What we do when beginning the procedure is to explore the abdominal cavity, we evaluate the compliance of the descending colon and sigmoid, and I think that in this case we can do the anastomosis on the sigmoid, it is not necessary to use the descending colon. We check that there is no carcinomatosis, you see the landmarks: we have the aorta, it seems that the origin of the IMA is there, here is the sacral promontory, pelvis. We will incise the peritoneum first, and it is easier to have a long and large flap, particularly close to the duodenojejunal junction. You see the vein and we go in the direction of the vein, IMV. We will now change the traction. The aim is to find the plane at the back of the vessels. I think that the best is to dissect anterior to the promontory in order to find the IMA, the superior rectal vessels and we see the back of the superior rectal vessels. We will slide on the back.

2. Vascular dissection 02'15''

Those branches are divided. These nodes will be removed. We will do the analysis of these nodes. This is the plexus trunk, the mesenteric plexus, we can complete the dissection of the vascular sheet to have the vessels only and we will see the division better. It seems like we have the IMA, the superior rectal vessels, the sigmoid trunk, it is not only the sigmoid but also the left colic with the sigmoid trunk there.

3. Vascular division 03'07''

We will divide the superior rectal vessels and the sigmoid trunk, Ligasure. Concerning the vein, we will divide it at about the same level, it doesn’t seem necessary to divide it to complete the closure with a clip. We can see the lower vascular sheet well because we have dissected while staying close to it to find the right plane. The vein normally runs lateral to the artery, I am dividing the branch. Lower the vein is anterior, and you see the left colic artery crosses anterior to the vein and I will divide the vein approximately at this level. I don’t think that this will change the outcome. To the retroperitoneal structures and in particular the ureter, we will see it soon. I am clipping the vein. I am putting another clip on this side because we will do some manipulation. We complete the dissection using traction and counter-traction, and as you see, we are rapidly against the Toldt’s fascia that is very close. Now the lateral freeing of the mesosigmoid because the first step of TME is to divide the vessels, IMA, or branches at their origin to free the sigmoid from the posterior and lateral attachments, in this case we do it medially, but we will complete now laterally. We will mobilize the sigmoid after the ligation of the vessels. You see that the sigmoid loop is very long, this is good for the colo-anal anastomosis, we will do it normally in this case.

4. Pelvic dissection 06'27''

We complete the lower freeing until we are close to the pelvic rim. Now we have freed the sigmoid, we will use a peanut swab to exert counter-traction for the retraction. We put some traction with the peanuts. We have to find the plane between the fascia propria and pre-sacral fascia. This is probably a plexus, this is the nerve or a vein perhaps, I don’t know. When we do the dissection of the vertical segment of the rectum, male or female, it is similar, we shouldn’t do too short a dissection but a very large one from right to left, we see the nerve running. I am sliding medial to the parietal fascia. Lower I’m a little back so we are doing the division of the posterior attachment of the vertical segment of the rectum, until we reach the vertical and horizontal part of the rectum. We use a 0 degree scope to do that. We have the pre-sacral vessels, we have the fascia, we have nerves not far. We are behind the parietal fascia, that is why we can see so well the pre-sacral vessels. We have dissected enough posteriorly, perhaps we will do more on the right, and to do a better division of the lateral attachments, we will do the division like this. We see the nerve running lateral to the parietal fascia. We will not cut the peritoneum too rapidly. The idea is to slide on the parietal fascia we see very well there, and because we have a good traction, we see the white line, the limit between the parietal fascia. This opens up the plane. As you see, the sacral branches are not far from my scissors.

5. Anterior dissection 10'50''

I’m showing you how we find the planes, they are coming. We will continue anterior. So first, we will pull on the rectum, the rectosigmoid in this way. We will open the pre-rectal space. We will incise the peritoneum now 1cm above the Douglas’ pouch. If we are too deep, we will be anterior to the Denonvilliers’ fascia. We can see very well to the right the vas deferens or the seminal vesicle, we will pull now like this. We open the plane back to the Denonvilliers fascia. To dissect anterior to the Denonvilliers’ fascia is better for the preservation of the nerve. We are sliding between the 2 planes: you see the small attachment that we free like this. Slowly we are reaching the pelvic floor. We have now finished dissecting more anteriorly. We can see very well the white tissue, yellow, the limit, but when there is not enough tension, it is better to cut to find the plane. We have now opened the plane, we change by putting an anterior retractor. We introduce a small T-retractor to keep the plane. We are inside the Denonvilliers’ fascia to stay anterior to the rectum. We are now reaching the pelvic floor, we see the nerves very well. We have to stay just close to the fascia propria of the rectum. We are putting a longer one, it’s the same but it is to have the possibility to retract deeper. We see the importance of the retraction, and a good retraction to see and to dissect. We continue the dissection. We don’t use too much energy because we use 15 Watts for the dissection. We will do everything with the monopolar as described by Bill Heald.

6. Posterior dissection 16'45''

Now we will do the posterior dissection of the lower rectum. This is fusion between the pre-sacral fascia and the fascia propria of the rectum, and we have dissected the fascia propria of the rectum. We will divide it because if we don’t, we will have a problem. We are dividing as you can see. This is the sphincter. We will complete the dissection anterior and lateral. You see the pelvic floor on this side. We have contraction of the pelvic floor. The best is to free the mesorectum from the pelvic floor and this is what I’m doing now. I want to respect the plexus. I will use traction by grasping, perhaps it’ll be better. I try to do posterior like this. So we have finished the dissection. Now we will divide the sigmoid. We will choose a segment of sigmoid where we will do the anastomosis. Let this fall. I think that using this well vascularized segment as you see will be very good. We have to verify the vascular package. It is lower and we understand why it is well vascularized. We can take down this segment. We remove the retractor and we introduce the forceps to expose the sigmoid.

7. Mesosigmoid and sigmoid division 20'30''

We will watch if the vessels are beating. They are as you see. We use an Endo-GIA 60mm. I’m removing the segment of colon and rectum separately. I’m not pulling outside because I’ll do the extraction trans-anally and also I don’t want to manipulate the rectum and the colon. This will go down without any problem. We will do with a small reservoir. Vessels are always beating.

8. Perineal step 21'52''

We will do the perineal step.

9. Specimen extraction and coloanal anastomosis 22'01''

Now we will do the extraction. You can clearly see the rectum and the area where there was the tumor. We are going to incise here. Here was the pelvic floor and the posterior lesion. This explains why I’m doing an intersphincteric. This is a marisca.

10. Ileostomy and pelvic drain 26'45''

I’m pulling a drain too. For that, we put the patient head down. We push the catheter inside.

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